RESPONSE TO LETTER Laparoscopic Hepatectomy Under Epidural Anesthesia Without General Endotracheal Anesthesia: Feasible but Applicable? Reply:
W
e have read with interest the work of Dr Yamamoto and colleagues from the Yamamoto Memorial Hospital in Imari City, Japan. Their group describes the first case of laparoscopic hepatectomy under epidural anesthesia without general endotracheal anesthesia.1 This group has previously reported their experience with open hepatectomy under similar anesthesia.2 Their open series included 10 hepatectomies consisting of a left lateral sectionectomy, 4 left lobectomies, and 5 partial resections with an average blood loss of around 500 mL but varied between 150 and 1500 mL. We congratulate the authors on this technical innovation but consider the applicability of such a procedure in European and North American centers challenging due to the significant expertise and field strength required. The use of combined epidural and regional anesthesia has long been recognized as an alternative for laparoscopic cholecystectomy in high-risk patients with chronic
obstructive pulmonary disease.3 This anesthetic approach is effective but has not gained traction in other right upper-quadrant or intraabdominal cancer operations. Recent trials comparing patient-controlled anesthesia with epidural anesthesia identified an increased incidence of coagulopathy and blood loss with epidurals.4,5 In the current report, Yamamoto and colleagues do note that their institution has had more than 50 years of experience and 3000 open abdominal operations in gastrointestinal malignancies, making his the ideal institution to achieve this surgical innovation. As with any surgical innovation, one must consider is there adequate expertise and field strength to apply this technique. It seems, in this instance, that this institution was exceptionally poised for this innovation. However, laparoscopic hepatectomy is a challenging procedure with a significant potential for complications that should be performed in high-volume centers with expertise in both open liver surgery and advanced laparoscopy. As noted, Yamamoto and colleagues reported at least one case with significant blood loss, confirming the potential challenges in this procedure. We believe this procedure is a new addition to our surgical armamentarium, but due to its stringent requirements, it should be reserved for patients with significant comorbidities requiring this approach. We congratulate Dr Yamamoto and his group but recommend others proceed with caution as is with any surgical innovative; adoption of this procedure requires significant anesthetic
expertise and field strength. We recognize the potential benefits of hepatectomy under epidural and regional anesthesia but note the increased incidence of coagulopathy with epidural anesthesia and the real potential for aspiration in complicated procedures that require rapid conversion to general endotracheal intubation. This procedure is a new surgical innovation that should be examined carefully and reserved for high-risk patients who would receive benefits from the riskbenefit ratio. Joseph F. Buell, MD, MBA, FACS
REFERENCES 1. Yamamoto K, Ishizawa T, Kokudo N. Laparoscopic hepatectomy under epidural anesthesia. Ann Surg. 2014;260:e1. 2. Yamamoto K, Fukumori D, Yamamoto F, et al. First report of hepatectomy without endotracheal general anesthesia. J Am Coll Surg. 2013;216:908–914. 3. Gramatica L, Jr, Brasesco OE, Mercado Luna A, et al. Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease. Surg Endosc. 2002; 16:472–475. 4. Wong-Lun-Hing EM, van Dam RM, Welsh FK, et al. Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy. HPB (Oxford). 2014;16:601– 609. 5. Shontz R, Karuparthy V, Temple R, et al. Prevalence and risk factors predisposing to coagulopathy in patients receiving epidural analgesia for hepatic surgery. Reg Anesth Pain Med. 2009;34: 308–311.
From the Tulane Transplant Institute, New Orleans, LA; Departments of Surgery and Pediatrics, Tulane University, New Orleans, LA; and Louisiana State University Health System, New Orleans, LA. Disclosure: The author declares no conflicts of interest. Reprints: Joseph F. Buell, MD, MBA, FACS, Tulane Transplant Institute, 1415 Tulane Ave, #HC-5, New Orleans, LA 70112. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-e0002 DOI: 10.1097/SLA.0000000000000815
e2 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
W
e have read with interest the work of Dr Yamamoto and colleagues from the Yamamoto Memorial Hospital in Imari City, Japan. Their group describes the first case of laparoscopic hepatectomy under epidural anesthesia without general endotracheal anesthesia.1 This group has previously reported their experience with open hepatectomy under similar anesthesia.2 Their open series included 10 hepatectomies consisting of a left lateral sectionectomy, 4 left lobectomies, and 5 partial resections with an average blood loss of around 500 mL but varied between 150 and 1500 mL. We congratulate the authors on this technical innovation but consider the applicability of such a procedure in European and North American centers challenging due to the significant expertise and field strength required. The use of combined epidural and regional anesthesia has long been recognized as an alternative for laparoscopic cholecystectomy in high-risk patients with chronic
obstructive pulmonary disease.3 This anesthetic approach is effective but has not gained traction in other right upper-quadrant or intraabdominal cancer operations. Recent trials comparing patient-controlled anesthesia with epidural anesthesia identified an increased incidence of coagulopathy and blood loss with epidurals.4,5 In the current report, Yamamoto and colleagues do note that their institution has had more than 50 years of experience and 3000 open abdominal operations in gastrointestinal malignancies, making his the ideal institution to achieve this surgical innovation. As with any surgical innovation, one must consider is there adequate expertise and field strength to apply this technique. It seems, in this instance, that this institution was exceptionally poised for this innovation. However, laparoscopic hepatectomy is a challenging procedure with a significant potential for complications that should be performed in high-volume centers with expertise in both open liver surgery and advanced laparoscopy. As noted, Yamamoto and colleagues reported at least one case with significant blood loss, confirming the potential challenges in this procedure. We believe this procedure is a new addition to our surgical armamentarium, but due to its stringent requirements, it should be reserved for patients with significant comorbidities requiring this approach. We congratulate Dr Yamamoto and his group but recommend others proceed with caution as is with any surgical innovative; adoption of this procedure requires significant anesthetic
expertise and field strength. We recognize the potential benefits of hepatectomy under epidural and regional anesthesia but note the increased incidence of coagulopathy with epidural anesthesia and the real potential for aspiration in complicated procedures that require rapid conversion to general endotracheal intubation. This procedure is a new surgical innovation that should be examined carefully and reserved for high-risk patients who would receive benefits from the riskbenefit ratio. Joseph F. Buell, MD, MBA, FACS
REFERENCES 1. Yamamoto K, Ishizawa T, Kokudo N. Laparoscopic hepatectomy under epidural anesthesia. Ann Surg. 2014;260:e1. 2. Yamamoto K, Fukumori D, Yamamoto F, et al. First report of hepatectomy without endotracheal general anesthesia. J Am Coll Surg. 2013;216:908–914. 3. Gramatica L, Jr, Brasesco OE, Mercado Luna A, et al. Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease. Surg Endosc. 2002; 16:472–475. 4. Wong-Lun-Hing EM, van Dam RM, Welsh FK, et al. Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy. HPB (Oxford). 2014;16:601– 609. 5. Shontz R, Karuparthy V, Temple R, et al. Prevalence and risk factors predisposing to coagulopathy in patients receiving epidural analgesia for hepatic surgery. Reg Anesth Pain Med. 2009;34: 308–311.
From the Tulane Transplant Institute, New Orleans, LA; Departments of Surgery and Pediatrics, Tulane University, New Orleans, LA; and Louisiana State University Health System, New Orleans, LA. Disclosure: The author declares no conflicts of interest. Reprints: Joseph F. Buell, MD, MBA, FACS, Tulane Transplant Institute, 1415 Tulane Ave, #HC-5, New Orleans, LA 70112. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-e0002 DOI: 10.1097/SLA.0000000000000815
e2 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
